The facts of the Co Galway case involving the rape of three children who were in foster care indicate a failure to implement the obligation on the State to remove children from perceived risk to harm.
According to RTÉ's Prime Time investigation on the case, the Co Galway home continued to be used as a foster home after a complaint had been made by one of the foster children against the natural son of the foster parents.
A file was sent to the Director of Public Prosecutions but no charges were brought.
However, it appears the fact of the allegation was known to the Health Service Executive as measures were put in place designed to protect the children against the concerns that had been raised.
Keith Burke was recently sentenced to 7½ years in prison, with a year suspended, after he was found guilty of raping the then-three foster children between 2003 and 2007.
According to the RTÉ report, the HSE was told in 2007 that Burke had left home, was living nearby, and would no longer be allowed unsupervised access to the children. His parents, the foster parents, were to supervise the arrangement. But Burke continued to visit the home after this new arrangement was put in place.
Experts say that any risk assessment for the children concerned should have immediately led to their being removed from the foster home.
Strong suspicion
The law and policy are both clear that children have to be removed from situations where there is a strong suspicion that they may be in danger.
Resources difficulties and other such practicalities are not a reason for leaving a child at risk and why the services in Co Galway apparently decided to leave children in what appears to have been known to be a high-risk environment, is not clear.
A key issue for any report on the matter will be the extent to which the decision was based on an individual error, or was the result of a flawed policy on risk assessment that may have been operating in the region.
The State has a mandatory obligation to protect children in a pro-active fashion.
Child care workers and experts in the area who spoke to The Irish Times were shocked by the details of what happened in Co Galway, but not enormously surprised. All were agreed that the Irish child care service is over-stretched, and not designed to fit children's needs. (It is mostly a nine-to-five, Monday-to-Friday service.)
What is troubling about the Co Galway case is it is another instance of a failing in a case where the children concerned were already in care.
How what happened could have happened is currently the subject of an National Review Panel inquiry though some have called for a Commission of Investigation.
Capacity
However, experts said that the problem with the childcare sector is not the quality of the inquiries and the reviews that are conducted once failings have come to light, but rather the capacity of the system to put into effect the lessons that should be learned from the failures that are discovered and investigated.
Standard foster care assessments for families that want to provide the service look for any history of abuse so how a home could have continued to be considered suitable for use once a serious allegation had been made against a member of the family concerned, is the key question that needs to be answered, experts said.
The Irish system involves a lot of work going into assessing prospective suppliers of foster care, one expert said, but a lot less work goes into the issue of intervening once a concern has been raised.